Care Review Clinician I (71822)

Davita Inc.; Houston (TX); Remote; USD 60,000 - 80,000; Full time

Job summary

A leading healthcare company is seeking a fully remote Care Review Clinician I responsible for evaluating medical necessity requests. The role requires a licensed RN or LPN with at least one year of experience in Utilization Management. The clinician will review prior authorizations and collaborate with multidisciplinary teams to ensure quality member care.

Qualifications

• At least 1 year Utilization Management experience in a healthcare setting.
• Able to work remotely in a high pace and demand environment.
• Experience with MCG guidelines is preferred.

Responsibilities

• Review prior auth/Inpatient/Skilled Nursing requests for medical necessity.
• Analyze clinical service requests against evidence-based guidelines.
• Conduct prior authorization reviews to determine financial responsibilities.

Skills

Utilization Management experience

Clinical analysis

Telehealth

Education

RN or LPN license

Tools

QNXT

UMK2

PEGA

Job description

Care Review Clinician Iwork with the Utilization Management team primarily responsible for inpatient medical necessity/utilization review and other utilization management activities aimed at providing members'ultimate care.MUST be licensed RN or LPN inTexas or Compact. This position is FULLY REMOTE. Schedule M-F 8am-5pm EST or CST.



Day to Day Responsibilities:

Review Prior auth/Inpatient/Skilled Nursing requests for medical necessity using State/Policy or MCG criteria.



KNOWLEDGE/SKILLS/ABILITIES

* Provides daily review and evaluation of members that require hospitalization and/or procedures providing prior authorizations and/or concurrent review

* Analyzes clinical service requests from members or providers against evidence based clinical guidelines.

* Identifies appropriate benefits and eligibility for requested treatments and/or procedures.

* Conducts prior authorization reviews to determine financial responsibility for members.

* Processes requests within required timelines.

* Refers appropriate prior authorization requests to Medical Directors.

* Requests additional information from members or providers in consistent and efficient manner.

* Makes appropriate referrals to other clinical programs.

* Collaborates with multidisciplinary teams to promote Care Model

* Adheres to UM policies and procedures.



Must Have Skills:

at least 1 year UM experience in a HP setting

RN or LPN

The ability to work remote in a high pace/high demand environment.

The ability to complete 15-20 authorization in a day

Previous experience using QNXT/UMK2/PEGA preferred

MCG Experience preferred.



Required Years of Experience:

1 Required

Licensure / Education:

RN or LPN